STRINGS ATTACHED

A key spending requirement in the act that authorizes the President's Emergency Plan for AIDS Relief (PEPFAR) hampers some programs' efforts to reach the broadest population of individuals at risk of acquiring HIV infection.1 According to a study by the U.S. Government Accountability Office (GAO), the requirement that programs spend one-third of their PEPFAR prevention funds on interventions that promote abstinence until marriage has created several challenges for HIV prevention teams in the 15 countries that are PEPFAR's focus. Ten teams told GAO investigators that parts of the requirement were difficult to interpret and, therefore, to implement; half reported that meeting the requirement "can undermine the integration of prevention programs." And although PEPFAR emphasizes addressing local prevention needs, 17 of 20 country teams surveyed (the focus countries and five others) say that the requirement hampers their ability to do so. These 17 teams are able to comply with the requirement only at the expense of cutting expenditures on other program areas, such as reducing vertical transmission of the virus or developing prevention messages for high-risk groups. In response to the GAO report, the agencies that administer PEPFAR have agreed to collect and report information on the requirement's effect.

4.5 YEARS...AND COUNTING

An experimental vaccine that prevents infection with the two strains of human papillomavirus (HPV) that cause most cases of cervical cancer maintains its effectiveness for at least 4.5 years, according to results of an ongoing study.1 Throughout the follow-up period, women treated with the vaccine have maintained high levels of HPV 16 and HPV 18 antibodies, and have developed these viral strains at a significantly lower rate than women who received a placebo. The vaccine also appears to offer protection against two other HPV strains. Women who received the vaccine have reported fewer adverse health events than have those who received a placebo, perhaps, according to the investigators, because they have had fewer cytologic abnormalities. The researchers conclude that their findings "set the stage for the widescale adoption of HPV vaccination for prevention of cervical cancer."

UR OK; NO CT

Using text messaging to notify clients of STD test results can save clinics time and money, as well as reduce the amount of time it takes for infected individuals to begin getting treatment, according to a study examining the experience of a London sexual health clinic.1 During the first six months that it offered clients the option of receiving test results via text message, the clinic sent 952 STD results this way; in the final month, one-third of all test results were sent by text message, and the clinic saved 46 hours in staff time and 40% in associated costs. In all, 49 clients tested positive for chlamydia during the study period; 28 of them were notified via text message, and the rest by phone or on a return visit to the clinic. Those who got a text message learned of their results significantly sooner than did those notified via traditional means (on average, in eight days, compared with 13 days); the interval from the test to the beginning of treatment also was shorter for those in the text message group than for those getting test results by phone or in person (medians, nine and 15 days, respectively). According to the researchers, by facilitating "the communication of relevant information to patients in a timely manner," text messaging has "a positive impact on individual and public health."

MIND-BODY PROBLEM

Psychosocial stress may be a factor in the development of bacterial vaginosis, a condition that can lead to adverse obstetric outcomes, genital tract infections and increased susceptibility to STDs.1 In a yearlong longitudinal study of nonpregnant 15–44-year-old women attending an Alabama clinic, the odds that a woman had bacterial vaginosis at the time of any given visit increased by 10% for every one-point increase in her score on a standard scale measuring psychosocial stress. Moreover, the odds that a woman who did not have bacterial vaginosis at one visit had it at the next rose by 29% for every one-point increase on the stress scale. These associations were statistically significant and were independent of the effects of demographic and behavioral characteristics. According to the researchers, the findings suggest that the effect of stress "is related to the development of [bacterial vaginosis] rather than its maintenance over time"; the investigators acknowledge the need for additional research exploring the mechanisms underlying this effect.

1. Nansel TR et al., The association of psychosocial stress and bacterial vaginosis in a longitudinal cohort, American Journal of Obstetrics and Gynecology, 2006, 194(2):381–386.

WHAT THE BRITISH KNOW (AND THINK) ABOUT HIV

Seventy-nine percent of British adults surveyed in 2005 knew that HIV can be transmitted through unprotected sex between men, and the same proportion knew that the virus can be spread through unprotected heterosexual intercourse—lower proportions than five years earlier (88% and 91%, respectively).1 Only 16% of respondents in the nationally representative sample were aware that HIV can be transmitted from a breast-feeding mother to her child, and 8% said they did not know how the virus is spread. Twenty percent of those surveyed said that they did not know enough about the risks of HIV and AIDS to people like themselves, and 43% considered themselves not at risk. Among those who had had a new partner in the last two years, not quite half said that they would always use a condom with a new partner, and one in 10 said that they never would. More than two decades into the pandemic, three-fourths of British adults believe that "there is still a great deal of stigma" about HIV and AIDS in their country, and close to half think that individuals who become infected through unprotected sex or through drug use "only have themselves to blame"; 7% do not deem HIV-infected people worthy of the same support and respect as people with cancer. Although 57% would feel comfortable knowing that a coworker had HIV, 36% would expect to be informed if that were the case.

WHY NOT SCREEN FOR ABUSE?

A study of postpartum women in two maternity facilities may help alleviate doubts about the acceptability and effectiveness of universal domestic violence screening for pregnant women.1 In computerized self-interviews completed within 72 hours after they gave birth, 60% of participants reported having been screened for physical, sexual or emotional abuse while pregnant, two-thirds of them by their regular prenatal care provider. Virtually all of those whose prenatal care provider had screened them for abuse—97%—said that the questions had not embarrassed, angered or offended them. However, not all women disclose abuse to their provider even during screening: Of those who indicated that they had been abused and been screened for abuse, only 17% said that they had told their prenatal care provider about the abuse. Lack of knowledge about relevant laws may help explain women's reluctance to report abuse during pregnancy. Just one-third of women knew that violence is reportable to authorities only if it results in serious harm or entails use of a lethal weapon; 6% said that they would have given a different answer during screening if they had known the reporting laws. The researchers consider it "essential that the goal [of universal screening] remain a priority for both researchers and clinicians."

TOYS, DRUGS AND OTHER RISKS

Many people who use devices or drugs to enhance sexual experience also engage in other behaviors that may increase their STD risk, according to results of a 2003–2004 telephone survey of Seattle-area 18–39-year-olds.1 Nearly three in 10 of the 1,114 sexually active respondents reported using a sex toy at least once in a typical four-week period, and more than one in 10 a drug to enhance sexual pleasure (most often, alcohol, marijuana, ecstasy or sildenafil). In multivariate analyses, use of sex toys was positively associated with being female, having an increasing number of recent partners, having met the most recent partner on the Internet, having had oral or anal sex with the most recent partner, using drugs to enhance sexual experience and drinking (odds ratios, 1.2–3.0); the odds of using sex toys were reduced for individuals in mutually monogamous relationships (0.6) and declined with increasing age at first sex (0.9). Respondents in mutually monogamous relationships also had reduced odds of using drugs to enhance sexual experience, as did those who reported that their last partner knew their families (0.5 for each); the odds were elevated for never-married individuals, those who had had anal sex with their last partner, those who used sex toys and those who drank (1.5–2.2). The analysts conclude that questions about these behaviors may help clinicians identify candidates for in-depth risk assessment and STD testing.

1. Foxman B, Aral SO and Holmes KK, Common use in the general population of sexual enrichment aids and drugs to enhance sexual pleasure, Sexually Transmitted Diseases, 2006, 33(3):156–162.

MIRROR, MIRROR ON THE WALL...

College students' sexual behavior and attitudes may be linked to their body image, and some associations differ for males and females.1 In a survey of 434 first-year students, those who were sexually experienced were significantly more concerned about their appearance, more pleased with their appearance and less dissatisfied with their body than were their sexually inexperienced peers. Among men, the greater the concern with and evaluation of personal appearance, the greater the lifetime number of sexual partners; the prevalence of unprotected sex also was positively correlated with appearance evaluation. Among women, body image was not associated with the lifetime number of partners; however, a history of unprotected sex was negatively correlated with appearance evaluation, and alcohol use before or during sex was positively correlated with dissatisfaction with one's body. For both males and females, concern with appearance was positively correlated with adherence to a sexual double standard. Noting that "being quite positive in body evaluation may actually lead to riskier behaviors" for males, the investigators recommend that programs for young men address body image "within a comprehensive program that focuses on other issues, such as healthy sexuality and respecting women." For young women, by contrast, "focusing on body image may be an effective way to reduce…risky attitudes and behavior."

1. Gillen MM, Lefkowitz ES and Shearer CL, Does body image play a role in risky sexual behavior and attitudes? Journal of Youth and Adolescence, 2006, DOI:10.1007/s10964-005-9005-6.